Spontaneous Rectus Sheath Hematoma: Two Variant Cases
Kamesh Sivagnanam, MD; Vatsal Ladia, MD; Vedang Bhavsar, MD; Jeffery Summers, MD; Timir Paul, MD, PhD
We present two variant cases of spontaneous rectus sheath hematoma (SRSH). A 71-year-oldwoman presented with ST elevation myocardial infarction and was found to have multivessel coronary artery disease. She was treated with aspirin, clopidogrel, eptifibatide, and heparin. Heparin was continued while preoperative workup for coronary artery bypass grafting was done. She developed a large 20x10 cm actively bleeding SRSH while on heparin. It was surgically evacuated. The second case represents an atypical cause of SRSH. A 64-year-oldwomanwithWegener’s Granulomatosis presentedwith anemia and abdominal pain. Abdomi- nal CT showed a large 22 cm SRSH without active bleeding that was treated conservatively. Both patients did well on follow-up. The incidence of SRSH is likely to increase in the coming years with the increasing use of antithrombotic agents for many disease processes. Clinicians should be aware of typical and atypical presentations of SRSH and its variant management options.
INTRODUCTION Spontaneous rectus sheath hematoma (SRSH) is an uncommon cause of abdominal pain, with an estimated incidence of 1 in 10,000 emergency visits. 1 Approximately 73%-100% cases of SRSH are associated with anticoagula- tion 2 and are rarely associated with vasculitis. 3,4 CASE 1 A 71-year-old female presented with chest pain radiat- ing to her left arm. She had a history of myocardial infarc- tion and drug-eluting stent placement to the right coronary artery and left anterior descending artery (LAD). Other medical problems included hypertension and tobacco use. Her medications included metoprolol, ranolazine, simvas- tatin, aspirin, and clopidogrel. Her vitals were stable, and physical examination was unremarkable. An EKG showed ST segment elevation in anterior leads. Troponins were mildly elevated at 0.03 ng/ml (normal – <0.02 ng/ml). She was given full dose of aspirin and a loading dose of clopidogrel. An emergent left heart catheterization showed in-stent thrombosis of the LAD stent and multivessel coro- nary artery disease. She underwent balloon angioplasty to the LAD with good angiographic results. Intravenous bivalirudin (bolus and infusion) was used as anticoagulation during the procedure. It was felt that she would have bet- ter outcome from coronary artery bypass grafting (CABG) comparedwithmultivessel percutaneous intervention. Post- catheterization, she was started on eptifibatide and heparin drips. Her aPTT ranged between 24-80 seconds (normal – 25
to 35 seconds). Eptifibatide was stopped after 18 hours, and heparin was continued. Her platelet count at this time was mildly reduced (lowest count of 120/mm3). On day four of her hospital stay, she developed severe left upper quadrant abdominal pain associated with a palpable mass. An ultra- sound of the abdomen showed fluid collection in this area that measured 8.7 cm x 5.6 cm. A CT scan confirmed the presence of a rectus sheath hematoma with extravasation of contrast, suggesting active bleeding (Figure 1). There was a significant increase in the size of the hematoma measuring 20 cm x 10 cm by CT scan, which was performed within two hours of the ultrasound. Her hemoglobin dropped from11.1 g/dl to 8.1 g/dl during this time (normal hemoglobin for women - 12.1-15.1 g/dL). Heparinwas stopped, and she was transfused with two units of packed red blood cells (PRBC). The rectus sheath hematoma was surgically evacuated and approximately 500 cc of non-clotted old bloodwas removed. After suturing the incision site, a wound vac was placed inferiorly in the left upper quadrant draining the rectus sheath. She recoveredwell andwas hemodynamically stable with no further evidence of subsequent bleeding over the next seven days. Her wound vac was then removed, and she underwent CABG. She recoveredwell postoperatively. Since the patient had the hematoma removed and had no further evidence of an active bleed and was hemodynamically stable, she was discharged on aspirin 81 mg and clopidogrel 75 mg every day. CASE 2
A 64-year-old woman was referred to the ER by her
J La State Med Soc VOL 166 September/October 2014 197
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